Sam Uretsky

Health Care Comes Down to Dollars

The New England Journal of Medicine, in a report published in the Aug. 21 issue, estimated that the cost of vaccinating pre-adolescent girls against human papilloma virus, the virus that causes genital warts and cancers, and concluded that the benefits may cost as much as $140,000 for every QALY. QALY stands for quality-adjusted life-year and is the standard measure of whether a treatment is worth the price. While there has been a great deal of publicity favoring injecting everybody with the vaccine against this virus, Mercks Gardasil, there seems to be a reconsideration going on. While Merck provided an effective advertising campaign, there was a simultaneous media frenzy pushing for the vaccine, with television physicians recommending that every girl be vaccinated, at $360 per vaccination. Now, with more information about the duration and effectiveness of the vaccine, theres a rush to reconsider. The usual guideline is to look for programs that cost no more than $50,000 per QALY.

People die. Invariably. Medical treatments can prolong life, but at a price and, like it or not, there has to be a measurement to determine the cost/effectiveness of a treatment. The measurements have limited value. They may be inaccurate and they ignore subjective factors, but theyre the only guide when it comes to allocation of resources. On Aug. 4, the US Preventive Services Task Force recommended that prostate cancer screening be discontinued for men after they reach the age of 75. The reasoning is that prostate cancer is normally slow growing, and by that age prostate cancer is unlikely to influence overall survival. While eliminating screening means that some men will ultimately die of prostate cancer who would otherwise have been treated, this may be balanced by the men who will avoid needless treatment and the risk of serious complications. The resources can be shifted to something that will offer greater benefit.

Like it or not, we do ration health care, and the distribution is far from equal. At one end of the spectrum are the super-rich, who can afford to keep a personal physician on salary. At the opposite end are the uninsuredwhose only source of treatment is the hospital emergency room. Sen. McCain and President Bush are right in saying that emergency rooms will treat uninsured patientsbut the treatment is the most basic, for the needs of the momentand since hospitals do send bills, and assign bills to collection agencies, this type of treatment carries its own risks.

In the middle are people with insurance, which helps a lotup to a point. Even then, third-party payers set limits, maximum expenses, formularies of drugs which theyll cover, with different co-pays, treatments which will be provided and which rejected. This is what passes for health care policy in the United States.

The debate over human papillomavirus vaccine is interesting, in part because its actual effectiveness wont be known for years. The only way to determine its cost effectiveness would be widespread distribution and observation. The NEJM article raises questions about how long the immunity lasts, and whether revaccination will be required. The result is another example of the division in availability of health care. For many families, the price of the vaccination, even as an out of pocket expense, is trivial and serious adverse effects extremely rare. As an individual decision its easy. The problem only arises when the decision has to be expanded to the millions of girls and women for whom the price is out of reach, so that the only possible approach is through a national program, with uncertain costs and unknown results.

Since every public health decision involves a trade-off, we need valid information, objective tools, and the ability to provide an organized response. We dont have that. We have elaborate systems that are so badly fragmented that its often impossible to get accurate statistics. A true national health service would give us the ability to make informed choices and act on them, but in an election year when the costs of health care have become major issues, the candidates are debating the best way to water the stew.

Compromise is generally good: It avoids fights. But in major social issues it usually just postpones those fights, like the medical resident whose goal is to have the patient die on somebody elses shift. This would have been a good year to reconsider all the details of our health system. We wont. We can always wait for a bigger crisis before we make a rush decision. Maybe thats just the American way.